Process of developing Country Cooperation Strategy in Tanzania, as an effective tool for aligning WHO’s support to the member state in achieving health and health-related sustainable development goal

Introduction an organization’s long-term success and relevance are linked with compelling strategic development. To that end, the country office of WHO in the United Republic of Tanzania, in collaboration with stakeholders, developed a 6-year Country Cooperation Strategy (CCS), 2022-2027. This paper describes the various steps taken in developing the CCS for the United Republic of Tanzania. Methods we reviewed the global guideline for the development of CCS. In addition, we analysed documents on the national health sector strategic plan, the 13th Global Program of Work for WHO (GPW13), and the Sustainable Development Goal (SDG). We also reviewed data from routine HMIS, the Global Burden of Disease (GBD), and assessment results of the UN on the status of SDGs through the Common Country Assessment (CCA). Results the performance on the overall Universal Health Coverage (UHC) effective coverage index, on a scale of 0-100, for Tanzania improved from 45.2 in 2010 to 55.2 in 2019. Strengthening health systems, protecting communities against public health emergencies, reducing or controlling exposure of individuals to risk factors, and better health governance, leadership, and accountability were the identified priorities for the CCS. Conclusion the process of alignment of the CCS document with the national and global strategic goals would help the WHO to support and lead the country’s effort towards achieving health-related SDGs. We believe the process we employed will lead to having detailed operational plans for implementation for achieving SDG targets. Keywords Country cooperation strategy (CCS), sustainable development goal (SDG), strategic document, 13th global program of work (GPW13), health sector strategy, stakeholders, Tanzania


Introduction
A literature review on the role of strategic planning by Kraus et al. emphasizes its importance in the predictability of possible future scenarios and variations as well as a central instrument for the strategic management of goals and visions of an institution changing [1]. Any organization´s long-term success and relevance are linked with a compelling strategic development process; various studies on this line demonstrated that comprehensive strategic planning contributes towards better organizational performance [2][3][4]. Strategic planning is a practice of management that links planning exercise with implementation, an ongoing process. It is a tool for accountability and compliance [5].
The United Nations (UN) Sustainable Development Goal (SDG) 3 is among the 17 goals that member states agreed to achieve by 2030. Goal 3 is to ensure healthy lives and promote well-being for all ages. Countries should have a strategic approach and plan to address the 13 targets under this goal. Clear obligations and responsibilities for all member states call for developing a strategic approach to be on track with targets. All countries are expected to take ownership and establish a strategic framework in line with the SDGs, to be on track with the goals [6,7]. WHO developed the thirteenth General Program of Work (GPW13) as a strategic approach to lead member states to attain health-related SDGs. This strategic document guides member states on high-level outcomes and outputs each country focuses on to achieve country-specific targets. It also provides a framework for countries to monitor global targets in health [8,9].
The Tanzania Development Vision 2025 states that attaining primary health care is one of the means to achieve a high-quality livelihood for the nation. In addition, the various national policies, such as the fifth Health Sector Strategic Plan 2016-2025 (HSSP V), sustainable and rapid reduction of maternal, newborn and child deaths and overall improved access to related quality services all highlighted the government priorities in health and areas of collaboration with stakeholders in strategic plans and implementations [10][11][12]. The UN developed a framework as one country team to support the government´s effort to achieve the SDG targets. The common country assessment of the UN support for the country to achieve SDGs highlighted non-communicable disease, quality of care, and challenges in the health system are roadblocks on the way to achieving health-related SDGs [13]. WHO leads the health efforts of the UN in the UN framework and coordinates health partners. To that end, a Country Cooperation Strategy (CCS) is the WHO´s corporate framework strategy in response to country needs and priorities in line with GPW13. It addresses health and health-related SDGs [14].
The current CCS for the United Republic of Tanzania was developed in line with the challenges identified and the best practices that were recorded in the country. It is the WHO´s support at the three levels of the organization to support the country to be on track with health-related SDGs with the principle of leaving no one behind. This paper describes the various steps taken in developing the CCS for Tanzania for 2022-2027. It also describes the actions to implement the strategic priorities successfully.

Methods
Team to work on the preparation of the strategic document: at the beginning of October 2021, a working group comprising the WHO country office, the Ministry of Health and representatives of the WHO Regional Office for Africa and WHO headquarters was established to lead the process of developing the CCS. The group set terms of reference and a timeline of 6 months for completing the work, and a regular weekly meeting was scheduled to monitor the progress. We started the consultation process with the WHO Regional Office and headquarters supporting the process. The review was focused on the various steps and processes we should employ, lessons learned from other countries that went through the same process of developing similar documents and most notably on the focus of alignment with available national and global priority areas. We reviewed the global guideline for developing the country cooperation strategy, 2020, as a checklist and guide for alignment with national strategic and development plans and the priorities of the United Nations Sustainable Development Framework (UNSDCF) for Tanzania. We used an approach to learn the internal and external factors in achieving the targets. This approach included a situation analysis, a review of national and global strategic documents, stakeholder consultation, and an alignment of priorities ( Figure 1). The result of these assessments was used to formulate recommendations, including focused priority areas.
Review of health information and strategic plans towards sustainable development goals: we reviewed various documents indepth to learn the status of targets and priorities in the national health sector development plan toward achieving the health and health-related SDGs. We reviewed the global burden of disease data and information for Tanzania to observe trends. We analysed what causes the most deaths and the risk factors that drive the most deaths and disabilities in Tanzania [15,16]. We also reviewed the paper published by the global burden of disease collaborators on measuring universal health coverage based on an index of adequate coverage of health services. This method used three steps to determine adequate health coverage for each country. First, an analysis of the proxy coverage of selected 23 indicators (  Table 1 (suite 3)), second a calculation of the fraction of potential health gains associated with each indicator. Third, the overall Universal Health Coverage (UHC) effective coverage index was constructed by weighting each coverage indicator of the 23 selected indicators relative to its health gains fractions. This tool was effective in strategic planning in priority setting [17]. We used the routine health information reported through DHIS2/HMIS to see the achievements in various indicators. Indicators on reproductive, maternal, newborn, child, and adolescent health (RMNCAH), infectious disease control and prevention, non-communicable diseases (NCDs) and health systems were used to learn the strength and the gap in health delivery to the community. We reviewed the trend of the indicators over time.

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targets and the UN norms and standards. We used the internal Strengths and Weaknesses and external Opportunities and Threats (SWOT) analysis for the assessment findings. We reviewed the country´s progress in the triple billion targets stated in the GPW13. Since the GPW13 covers a 5-year plan (2019-2023), we used the end-of-biennium report for 2020 and 2021 that highlights the status of the various outputs selected by the country as a measure of progress in achieving the health-related SDGs in the country. The end of the biennium assessment analysed the achievements of technical support and enabling functions of WHO to the member state using the various outputs monitored across the biennium. Each of the outputs was analysed in detail across six dimensions: technical support, leadership, global goods or technical products, Gender Equity, Human Rights and Disability (GEHRD), value for money and results. We reviewed the outputs of the analysis to identify areas of strength and weakness in achieving the outputs. We reviewed the national health sector strategic plan for Tanzania Mainland and Zanzibar: our review focused on two areas: 1) the extent of alignment of the strategic priority areas with the global priorities of SDGs and GPW13; 2) the success and challenges in the achievements of the priority areas. We also reviewed the monitoring and evaluation framework for the national health sector strategic plan.

Stakeholder analysis and consultations:
we conducted stakeholder analysis and mapping exercises. After a brainstorming exercise in analysing the stakeholders, we mapped them based on key criteria on areas of collaboration to manage during the implementation of the CCS. We reviewed the literature on how a mix of stakeholders improves strategic planning. The reason behind this is those affected by decisions in the strategic plan priorities contribute to an effective process [18]. We had continuous engagement and consultations with the Tanzania Ministry of Health officials. We reviewed the available evidence and discussed the selection of critical priority areas and interventions that we should focus on to achieve results. In addition, a discussion was made on monitoring and evaluating the CCS document. We laid out a monitoring and evaluation framework for the CCS. We engaged all stakeholders to agree on the mechanism and timeline for monitoring the CCS (Figure 2).

Results
The performance on the overall UHC effective coverage index that covers 23 indicators in the health system, on a scale of 0-100, for Tanzania improved from 45.2 in 2010 to 55.2 in 2019. While among the 23 indicators in the index, maternal and newborn care and noncommunicable diseases scored below 20 ( Figure 3). Estimated death from all causes showed a decline over time. In 2019, based on the latest Global Burden of Disease (GBD) estimate for Tanzania, it was 624.5 deaths per 100000 population. The global estimate for the same period was 730.5 per 100,000. Communicable, maternal, neonatal, and noncommunicable diseases accounted for the country´s 10 top causes of death. The review of the common country assessment towards achieving SDGs identified 10 accelerators for Tanzania to be on track to the SDGs target. Four of the accelerators, addressing maternal health, reducing the adolescent birth rate, ending the epidemic of HIV, TB, and malaria, and addressing malnutrition amongst adolescent girls and young women and < 5-year-old children, were directly linked with health-related SDGs. The SWOT analysis of achieving the SDGs using the common country analysis revealed an improvement in geographical access to health services because of the increased construction of health facilities. In addition, outpatient department utilization per person per year increased to 0.85 in 2019 compared to 0.8 in 2016. The political commitment and availability of strong partnerships with the availability of strong strategic plans were observed as an opportunity for achieving health targets. The assessment revealed a maternal mortality rate of 556 per 10000 in 2015, which was higher than the 2010 figure. Only 50% of the target for availing health workers in health facilities was achieved.
The end of the biennium assessment for 2020/21 of WHO´s support for countries´ priorities on technical support has shown a gap in the inclusion of Gender, Equity, Human Rights, and Disability (GEHRD) in planning and implementation. Four strategic priorities were identified based on a detailed analysis of the country´s context. The identified priority areas are strengthening the health system, protecting health emergencies, reducing or controlling risk factors, and health governance, leadership, and accountability. A total of 13 intervention areas were identified for the four priority areas. The priority areas aligned with the priorities of the national strategic plan, the outcomes of the GPW13, the SDG targets, and the priority areas of the UN Sustainable Development Cooperation Framework for Tanzania (Table 2, Table 2 (suite)). A total of 25 Development Partners Group for Health (DPG-H) were mapped based on their area of focus for various health interventions. A total budget of >73 million US$ was proposed for implementing the CCS for 6 years; 59% of the budget is for health system strengthening, followed by protecting people from health emergencies of 23%. The remaining 18% of the budget is for preventing risk factors and governance and leadership functions. To support the country in achieving the national GPW 13 and health-related SDGs priorities in health, the WHO country office and stakeholders developed a 6-year CCS (CCS 2022-2027) midterm strategic document [19]. The strategic document articulated the support of the three levels of the organization (country office, regional and headquarters in WHO) to lead the partnership in the health agenda in the country. 01 234ÿ 63278ÿ 9 ÿ 91 2 ÿ 2 3ÿ 2 8 ÿ 3 3433ÿ 31 2 ÿ 3 1 ÿ 3 2 ÿ 34ÿ 333 ÿ ÿ 9 4 63 ÿ 671 34ÿ 1 73 ÿ 7 1 2 1 ÿ 82378 ÿ 383ÿ 3 1 3 ÿ 1 ÿ !3 ÿ 6 3ÿ 038 1 ÿ "1 1 ÿ #74 1 2 ÿ # !2883 ÿ $ 1 ÿ %3 & ÿ # 22ÿ ÿ ' 1 ÿ 8 4ÿ 3 1 ÿ 0 3 4ÿ 1 ÿ 93(31 3 ÿ 32ÿ 3ÿ 1 'ÿ ÿ ÿ 3 1 1 )*+ 2ÿ 28 ÿ ÿ 7ÿ ÿ 2 3 ÿ 1 ÿ 371 '1 ÿ 73 7ÿ 3ÿ 73 7, 3 ÿ 282 31 3 ÿ ' ÿ 3 & ÿ -./01 ÿ 34ÿ 056 73781 ÿ 9:; <= > ÿ 7

Discussion
A 6-year CCS was developed from 2022-2027 to support the United Republic of Tanzania towards achieving the health-related SDGs. This strategic document was aligned with the national health sector strategic plan, GPW13 and the SGDs. This alignment would help the WHO to support the country´s effort towards achieving health and health-related indicators. It is also aligned with the Tanzania United Nations Sustainable Development Cooperation Framework (UNSDCF 2022-2027). This would allow the WHO to discharge its responsibility of coordinating and leading the health intervention of the UN in the country. The availability of CCS 2022-2027 in the country office organizes the way WHO brings all health stakeholders in the country, and it also elaborates on the responsibility and accountability of all actors and clarifies priority areas, interventions, and indicators of success across time during the implementation period of the strategic plan. Hence, it facilitates collaboration and avoids duplications of efforts by encouraging value for money. This is in line with studies that confirm the analysis of alignment in the strategic plan by vision, mission and values across stakeholders found to be effective in delivering the desired outcomes. The key to ensuring country strategic plans, by extension, SDG goals, can only be achieved through multistakeholder partnerships and engagement [20,21].
We noted stakeholders´ skills, resources, leadership, and broader participation as a marker of success in the strategic plan. This is in line with the findings of C. Bloom stated that what contributes to the success of strategic plans. The situation analysis, use of evaluation findings in the health sector, and involvement of all stakeholders, including the leadership in WHO and the Ministry of Health, are best practices in developing the CCS that could be cited as a potential indicator for the success of the implementation of the strategic plan [22]. Though an assessment was done in the previous CCS implementation, an in-depth evaluation is lacking, which limits the availability of clear evaluation recommendations to be reflected in the current CCS. However, we reviewed the assessment and did a desk review of the previous CCS considering current health indicators to address issues that were not implemented.

Conclusion
The persistent involvement of stakeholders and the discussion to focus on priority areas and interventions for the 6 years of CCS in line with the national and global priorities helped to develop the CCS. We believe the process we employed will lead to having detailed operational plans for implementation for achieving SDG targets. We recommend developing a detailed business case for resource mobilization and charting the road for implementation. It is also essential to focus on monitoring performance and regular feedback mechanisms to ensure the investment in developing the strategic plan is in good use.